Week 15: Caring for a Patient With Cancer
Objectives
Describe the etiology, clinical manifestations, and collaborative management of neutropenia.
Discuss the role of the nurse in the prevention, detection, and treatment of cancer.
Explain the use of surgery, chemotherapy, and radiation therapy in the treatment of cancer.
Describe the nursing management of patients receiving chemotherapy, radiation therapy, and surgery for cancer.
Components of Blood (Be sure to reference CBC)
Plasma: Liquid component of blood
Blood Cells:
Erythrocytes (RBCs): Transport O2 and CO2
Value: 4.5 to 6 million cells per microliter for males and 4 to 5.5 million cells per microliter for females.
Leukocytes (WBCs): Immune response
Value: 5,000 to 10,000 cells per microliter for adults.
Granulocytes (Polys)
Function: Phagocytosis
Types: Neutrophils, basophils, eosinophils
Agranulocytes: Lymphocytes, monocytes
Platelets (thrombocytes): Crucial for clotting
Value: 150,000 to 450,000 platelets per microliter of blood.
Normal/Abnormal Lab Values
Hemoglobin (HGB):
Female: [12.0 - 16.0 g/dL]
Male: [13.5 - 17.5 g/dL]
Hematocrit (HCT):
Female: [37.0 - 47.0%]
Male: [42.0 - 52.0%]
Anemia: Deficiency in RBCs or poor hemoglobin/hematocrit quality
Pancytopenia: Suppression of entire CBC (WBCs, RBCs, and platelets)
White Blood Cell (WBC) Normal Ranges
WBC Count: 4000 - 10,500 cells/uL
Elevated WBCs (Leukocytosis): More than 10,500 cells/uL, often indicative of infection, inflammation, or stress within the body.
Decreased WBCs (Leukopenia): Less than 4000 cells/uL, which can suggest bone marrow suppression, autoimmune disorders, or the effects of certain medications.
Neutropenia: Neutrophils below 1500 cells/uL, characterized by an increased risk of infections due to the decreased ability to fight off pathogens.
Platelet Count: 150,000 - 450,000 cells/uL
Elevated Platelets: Thrombocytosis
Decreased Platelets: Thrombopenia
Thrombocytopenia
Definition: Disorder with an abnormally low number of platelets
Causes:
Inadequate production in the bone marrow
Examples: Aplastic anemia, leukemia, folate deficiency, Vitamin B12 deficiency, side effects of chemotherapy
Increased breakdown in the bloodstream, spleen, or liver
Examples: DIC, drug-induced thrombocytopenia, Immune thrombocytopenic purpura (ITP)
Assessment findings: Bleeding from the mouth, gums, nosebleeds, bruising, petechiae
Treatment: Dependent on the underlying cause
Nursing Care for Patients with Thrombocytopenia
Minimize injury risk:
Avoid razors, injections, and body piercings
Use a soft-bristle toothbrush
Prevent constipation and straining at stool
Prevent falls
Infection prevention: Steroid use increases infection risk
Assessment: Monitor for bleeding, mucous membranes, bruising, petechiae, and labs (platelets, H/H)
Care of Patients with Altered WBCs
Elevated WBC (Leukocytosis):
Causes: Infection, leukemia, immune system disorders, stress
Decreased WBC (Leukopenia):
Causes: Bone marrow disruption/damage, chemotherapy/immunosuppressive therapy, HIV/AIDS
Neutropenia: Decreased neutrophils, the largest component of WBCs
Monitor temperature and signs/symptoms of infection.
Initiate WBC growth factors to stimulate bone marrow production and help prevent further complications associated with low white blood cell counts.
Treatment: Depends on cause, may involve withholding chemotherapy
Neutropenic Precautions
Strict hand hygiene practices
Avoid fresh flowers and fresh unpeeled fruits/vegetables
Limit exposure to crowds and ill individuals
Assess for signs of infection/inflammation
Promote good nutrition: high protein, high-calorie, fluids
Understanding Cancer
Cancer Facts: Cancer is a heterogeneous group of diseases characterized by uncontrolled cell growth, which does not follow physiological demand.
Leading Causes of Death (2015 Data):
Heart Disease: 633,842
Cancer: 595,930
Others include chronic lower respiratory diseases, accidents, strokes, Alzheimer's disease, diabetes, influenza and pneumonia, nephritis, suicide, etc.
Benign vs. Malignant Tumors
Benign Tumors:
Grow locally, not invasive, not cancerous
Malignant Tumors:
Invade neighboring tissues, enter blood vessels, and metastasize to distant sites
Nursing Care of Patients with Cancer
The 7 Warning Signs of Cancer (C.A.U.T.I.O.N.)
C: Change in bowel or bladder habits
A: Sore that does not heal
U: Unusual bleeding or discharge
T: Thickening of breast tissue or lump
I: Indigestion or difficulty swallowing
O: Obvious changes to moles or warts
N: Nagging cough (lasting four weeks or longer)
Risk Factors for Cancer
Heredity: 5-10% of cancers; some specific types (breast and colon)
Age: 70% of all cancers occur in individuals > 65
Tobacco Use: Linked to multiple cancers
Alcohol Use: Further exacerbates risks associated with smoking
Stress: General, greater wear and tear on the body
Diet: High in fried, high-fat, low-fiber foods; charred foods, high red meat content
Occupational Risks: Exposure to known carcinogens, radiation, high-stress environments, infection through specific organisms
Sun Exposure
Nursing Assessment
Subjective Findings: Patients may report fatigue, pain, changes in appetite, and emotional distress related to their diagnosis.
Objective Findings: Skin examination may reveal erythema, dryness, or lesions, while vital signs may indicate changes in temperature or blood pressure, reflecting the patient's overall health status.
Diagnostics:
Imaging: X-ray, CT Scan, Ultrasound, MRI, Nuclear Imaging
Tissue Typing: Biopsy, Cytology
Tumor Markers include:
PSA (Prostate-specific antigen): prostate cancer
CEA (Carcinoembryonic antigen): colon cancer
Alkaline Phosphatase: bone metastasis
Effects of Cancer
Physiological Disturbances: Due to pressure or obstruction
Hematologic Alterations: Various blood-related complications
Anorexia-Cachexia Syndrome: Weight loss and muscle wasting
Pain: A critical concern for patients and families
Stress: Both physical and psychological impacts on the patient
Collaborative Cancer Care
Treatment Options
Surgery: Oldest form of cancer treatment, includes preventive, curative, or control measures
Chemotherapy: Utilization of chemicals for systemic therapy; requires careful monitoring of dosages
Radiation Therapy: Aimed at localized treatment; common for many cancer types; may be external or internal (brachytherapy)
Targeted Therapy and Immunotherapy: More recent advancements in the treatment of cancer
Palliative Care: Important for patients not responding to other treatment strategies
Goals of Cancer Treatment
Cure: Full recovery from the disease
Control: Manage symptoms and disease progression
Palliation: Focus on relieving symptoms for patients not likely to respond to curative treatment
Key Factors Influencing Treatment Decisions
Tumor location, size, extent of disease, cell type, and the patient's needs and desires
Staging and In Situ Cancer
Carcinoma in situ: Early-stage cancer, localized with no tendency to invade or metastasize
TNM Classification System: Assessing cancer extent based on:
T: Tumor size and invasiveness
N: Presence or absence of local lymph node metastases
M: Metastasis to distant organs
Example: Carcinoma of the Pancreas Staging according to TNM
T-stage:
Tis: Tumor limited to the mucous membrane
T1: Tumor limited to pancreas, diameter ≤ 2 cm
T2: Tumor limited to pancreas, diameter > 2 cm
T3: Tumor extends beyond the pancreas without arterial involvement
T4: Tumor invades crucial arteries
N-stage:
Nx: Lymph nodes can't be assessed
N0: No local lymph node metastases
N1: Local lymph node metastases present
M-stage:
MX: Metastasis can't be assessed
M0: No distant metastasis
M1: Distant metastasis present
Health Promotion Strategies
Routine check-ups and screenings: Essential for early detection and management of cancer
Client Awareness: Importance of acting on symptoms that may indicate cancer
Screening examples include:
Breast Cancer: Self-breast exams, clinical exams, mammograms
Colon Cancer: Fecal occult blood tests, sigmoidoscopy, colonoscopy
Cervical Cancer: Pap tests
Prostate Cancer: Digital rectal exam, PSA tests
Treatment Modalities
Surgical Therapy
Goals: Vary from elimination of risk to palliative care
Debulking procedures: Indicated when complete removal is unfeasible
Supportive/Palliative Care: Including placement of feeding tubes, central venous devices, etc.
Chemotherapy Overview
Systemic Therapy: Utilization of chemicals; considered a mainstay for solid and hematologic cancers
Administration: Calculated by body surface area and involves combination drugs, done PO, IM, or IV through a central venous access device (CVAD).
Intracavitary: injection into the peritoneum, bladder.
Intrathecal: injection into the subarachnoid space; used for metastasis to the CNS.
Intra-arterial: delivers the drug through the arteries supplying the tumor.
Side Effects of Chemotherapy
Common Side Effects:
Fatigue, Hair Loss, Loss of Appetite.
Alopecia: A common effect characterized by temporary or permanent hair loss that can occur during treatment; it can grow back as soon as 3 weeks after chemo administration.
Mouth Sores, Nausea, Vomiting.
Diarrhea, Skin Changes.
Erythrodysethesia syndrome (hand-foot syndrome): a condition characterized by redness, swelling, and pain on the palms of the hands and soles of the feet; it can cause ulcers and blisters.
Psychosocial issues: Patients may experience anxiety, depression, and social isolation due to their diagnosis and treatment, which can significantly affect their overall well-being and quality of life (commonly seen in women).
Potentially Serious Side Effects:
Infection, Bleeding or Bruising, Low Blood Cell Counts
Chemotherapy Agents: Non-discriminatory, affect normal cells, leading to adverse effects
Emergency Situations in Chemotherapy
Extravasation Injury: Can occur with irritant or vesicant agents
IV administration can be irritating, which can cause damage to the intima of the vein, causing phlebitis.
Vesicants may cause tissue breakdown/necrosis, leading to possible loss of the affected extremity.
Routine Monitoring: Of IV sites is essential; ports are often recommended (especially for vesicant therapies).
Radiation Therapy Overview
Definition: Often utilized as a nonsurgical treatment; significant for at least 50% of cancer patients
Types: External (teletherapy) and Internal (brachytherapy)
Gamma knife technology: cobalt.
Cyclotron: neutrons or protons.
Linear accelerator: ionizing radiation.
Low-energy beams: utilize non-ionizing radiation for targeted treatment, minimizing damage to surrounding tissues.
High-beam energy: delivers a concentrated dose of radiation directly to the tumor, effectively destroying cancer cells while sparing healthy skin tissues.
Total doses are divided into fractions, allowing for better recovery of healthy tissues between treatments and enhancing the overall effectiveness of the therapy.
Typically, once a day for 5 days a week for 2-8 weeks.
Effects of Radiation Therapy
Local Effects: Within the treated field with precautions to minimize skin impact
Simulation for Treatment: Mapping out radiation fields and protecting critical structures
Treatment fields are defined, filmed, and marked out on the skin to outline the field.
Nursing Management of Chemotherapy & Radiation Therapy
Monitoring Bone Marrow Suppression: Focus on blood counts and risks of infection
It can be life-threatening.
Tell patients to avoid contact with people who may be sick.
Nutritional Support: Address common GI reactions, incl. nausea, vomiting, and anorexia
Prophylactic administration of antiemetics.
Recommend frequent dental visits, soft-bristle toothbrushes, and regular oral hygiene practices to minimize discomfort and prevent infections.
Encourage small, frequent meals of high-protein and high-calorie foods.
Psychosocial Support: Address mental and emotional well-being through support systems
Fear of dependency, loss of control, family stress, or fear of death.
Pain Management: Both pharmacological and non-pharmacological methods to manage pain
Advanced Therapies
Immunotherapy and Targeted Therapy
Definition: Attack cancer cells directly with less collateral damage to normal cells
Considerations: Potential side effects such as flu-like symptoms
Administer acetaminophen before treatment and q4hr after treatment.
For severe chills/rigors: IV meperidine
Hormone Therapy & Hematopoietic Stem Cell Transplantation
Hormone Therapy: Utilizes medications to block hormones promoting cancer growth
Stem Cell Transplantation: Options include allogeneic, syngeneic, and autologous transplants
Patient Care Considerations
Risks of Infection and Malnutrition
Education on Signs of Infection: Urging patients to report fever over 100.4°F
Nutritional Needs: Emphasis on soft, high-protein, and easy-to-digest foods
Cachexia and Anorexia
Cachexia: A Syndrome causing weight loss and appetite loss; treatment may involve medications to stimulate appetite (megestrol acetate/magace).
Common Patient Issues
Impaired oral mucous membranes
Impaired skin integrity
Nausea management
Fatigue and activity intolerance
Risk for infection/bleeding
Distorted body image from treatments
Terminal Care and End-of-Life Considerations
Supporting families and patients: Discussions regarding end-of-life care, comfort measures, and dignity in dying (reference to video: A Lesson in Dying).